Driving assessment in preclinical Alzheimer’s disease: progress to date and the path forward

Bayat, Sayeh; Roe, Catherine M. · 2022 · Crossref

DOI: 10.1186/s13195-022-01109-1

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Summary

This mini-review addresses the emerging evidence linking driving behavior to preclinical Alzheimer’s disease (AD), a stage characterized by underlying biological pathology despite cognitive normality. The motivation stems from the increasing proportion of older drivers and the critical role driving plays in maintaining independence and quality of life. While the impact of symptomatic AD on driving fitness is well-documented, less attention has been paid to the preclinical stage. The authors aim to summarize current findings on how preclinical AD affects everyday driving and outline the path forward for using driving as a potential biomarker. The review synthesizes evidence from autopsy studies, biomarker analyses, and naturalistic driving assessments. Early evidence relied on neuropathological examinations of older drivers who died in traffic accidents, revealing high rates of neuritic plaques and incipient AD pathology. Subsequent research utilized in vivo AD biomarkers, including cerebrospinal fluid (CSF) ratios and positron emission tomography (PET) imaging, to correlate biological markers with driving performance. To overcome the limitations of self-reported questionnaires (recall bias) and on-road tests (limited generalizability and cost), recent studies employed mobile sensor technologies, such as the Driving Real-world In-Vehicle Evaluation System (DRIVES), to monitor naturalistic driving behaviors. These methods allowed for the assessment of everyday driving patterns in cognitively intact older adults with and without preclinical AD biomarkers. The findings indicate that preclinical AD is associated with subtle but detectable changes in driving behavior. Autopsy studies showed that a significant percentage of older drivers killed in accidents had AD pathology. Biomarker studies revealed that cognitively normal adults with higher CSF tau/Aβ42 ratios or amyloid PET binding exhibited more errors in on-road tests and a faster decline in driving performance over time. Naturalistic driving studies using GPS and mobile sensors found that individuals with preclinical AD drive less frequently, cover shorter distances, and exhibit fewer aggressive behaviors, such as hard braking or speeding, compared to those without pathology. Longitudinal data confirmed a greater decline in driving frequency and trip volume over 2.5 years for those with preclinical AD. Furthermore, machine learning models applied to daily driving behaviors demonstrated high sensitivity (84%), specificity (94%), and accuracy (86%) in predicting underlying biological AD. The authors conclude that everyday driving, a complex instrumental activity of daily living, is significantly linked to AD biomarkers even in cognitively normal individuals. This suggests that driving behavior could serve as a digital, cost-effective, and accessible biomarker for early AD identification. However, the authors caution that current evidence is derived from a small number of studies. Therefore, further research is required to establish the internal and external validity of driving assessments for widespread clinical use. They explicitly state that current findings should not yet inform policy or insurance decisions regarding driving ability.

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Topics

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• mci dementia driving
• cognitive impairment